Pub Date : 2024-08-08DOI: 10.1101/2024.08.06.24311529
Matthew Ahmadi, Nicholas Koemel, Raaj Biswas, Sonia Chen, Richard Pulsford, Mark Hamer, Emmanuel Stamatakis
Importance: Physical activity guidelines are predominantly based on questionnaire-based studies measuring only longer planned physical activity bouts (>10-15 continuous minutes). To date, short intermittent bouts of physical activity that may be beneficial for health ('micropatterns'), have counted very little towards physical activity guidelines (currently 150-300 minutes of moderate or 75-150 minutes of vigorous intensity activity per week). Objective: We examined all-cause and cardiovascular disease (CVD) mortality associations of wearable device-captured activity accumulated through intermittent moderate to vigorous (IMVPA; ≤3 min) and vigorous (IVPA; ≤1 min) intensity bouts, by guideline adherence for a) active adults (eg. doing at least 150 mins/wk of moderate or 75 mins/wk of vigorous intensity physical activity), and b) inactive adults (not meeting the above amounts). Design: Prospective cohort study Setting: UK Biobank Participants: 62,899 adults (mean age 61 years, 55.7% female) with wrist-worn accelerometer data, followed up for an average of 8.0 (SD= 0.9) years Exposures: Intermittent moderate-vigorous (IMVPA; ≤3 min) and vigorous (IVPA; ≤1 min) intensity bouts; stratified by participants meeting and not meeting physical activity guidelines. Main outcomes and measures: All-cause and CVD mortality obtained through linkage with the National Health Service (NHS) Digital of England and Wales or the NHS Central Register and National Records of Scotland. Cox restricted cubic spline regression were used to assess the dose-response associations. Results: There were 1,583 all-cause and 442 CVD deaths among 62,899 adults (mean age 61 years, 55.7% female). Micropatterns accrued IMVPA and IVPA showed linear beneficial dose response associations in both the inactive and active groups. We observed a 1.4 to 2.0-fold lower mortality risk among inactive compared to active adults. For all-cause mortality, a median 4.0 minutes/day of IVPA was associated with a hazard ratio (HR) of 0.40 [0.32, 0.52] in inactive adults and 0.74 [0.58, 0.95] in active adults, compared to not doing any IVPA. For CVD mortality, a median of 13.0 minutes/day of IMVPA was associated with an HR of 0.32 [0.22, 0.51] in inactive adults and 0.53 [0.37, 0.78] in active adults. Analogous patterns of dose-response were present when adherence to guidelines was assessed using questionnaire-based data that only considered continuous activity bouts lasting at least 10 minutes. Conclusions and relevance: Among participants not meeting guidelines, intermittent moderate-vigorous physical activity showed stronger beneficial dose-response association with all-cause and CVD mortality, compared to active adults, highlighting potential health benefits from brief activity bursts for less active adults. Considering such activity patterns are hardly represented in the evidence used to develop current guidelines, our findings support the transition of future guidelines towards wearables-informed e
{"title":"Micropatterns of physical activity in relation to all-cause and cardiovascular disease mortality: the stealth lifestyle factor?","authors":"Matthew Ahmadi, Nicholas Koemel, Raaj Biswas, Sonia Chen, Richard Pulsford, Mark Hamer, Emmanuel Stamatakis","doi":"10.1101/2024.08.06.24311529","DOIUrl":"https://doi.org/10.1101/2024.08.06.24311529","url":null,"abstract":"Importance: Physical activity guidelines are predominantly based on questionnaire-based studies measuring only longer planned physical activity bouts (>10-15 continuous minutes). To date, short intermittent bouts of physical activity that may be beneficial for health ('micropatterns'), have counted very little towards physical activity guidelines (currently 150-300 minutes of moderate or 75-150 minutes of vigorous intensity activity per week).\u0000Objective: We examined all-cause and cardiovascular disease (CVD) mortality associations of wearable device-captured activity accumulated through intermittent moderate to vigorous (IMVPA; ≤3 min) and vigorous (IVPA; ≤1 min) intensity bouts, by guideline adherence for a) active adults (eg. doing at least 150 mins/wk of moderate or 75 mins/wk of vigorous intensity physical activity), and b) inactive adults (not meeting the above amounts).\u0000Design: Prospective cohort study\u0000Setting: UK Biobank\u0000Participants: 62,899 adults (mean age 61 years, 55.7% female) with wrist-worn accelerometer data, followed up for an average of 8.0 (SD= 0.9) years\u0000Exposures: Intermittent moderate-vigorous (IMVPA; ≤3 min) and vigorous (IVPA; ≤1 min) intensity bouts; stratified by participants meeting and not meeting physical activity guidelines. Main outcomes and measures: All-cause and CVD mortality obtained through linkage with the National Health Service (NHS) Digital of England and Wales or the NHS Central Register and National Records of Scotland. Cox restricted cubic spline regression were used to assess the dose-response associations. Results: There were 1,583 all-cause and 442 CVD deaths among 62,899 adults (mean age 61 years, 55.7% female). Micropatterns accrued IMVPA and IVPA showed linear beneficial dose response associations in both the inactive and active groups. We observed a 1.4 to 2.0-fold lower mortality risk among inactive compared to active adults. For all-cause mortality, a median 4.0 minutes/day of IVPA was associated with a hazard ratio (HR) of 0.40 [0.32, 0.52] in inactive adults and 0.74 [0.58, 0.95] in active adults, compared to not doing any IVPA. For CVD mortality, a median of 13.0 minutes/day of IMVPA was associated with an HR of 0.32 [0.22, 0.51] in inactive adults and 0.53 [0.37, 0.78] in active adults. Analogous patterns of dose-response were present when adherence to guidelines was assessed using questionnaire-based data that only considered continuous activity bouts lasting at least 10 minutes.\u0000Conclusions and relevance: Among participants not meeting guidelines, intermittent moderate-vigorous physical activity showed stronger beneficial dose-response association with all-cause and CVD mortality, compared to active adults, highlighting potential health benefits from brief activity bursts for less active adults. Considering such activity patterns are hardly represented in the evidence used to develop current guidelines, our findings support the transition of future guidelines towards wearables-informed e","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"60 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941412","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Multimorbidity, increasingly recognised as a global health challenge, has recently emerged on the health agendas of many lower-income countries, including in Africa. Yet with its conceptual origins in the global North, its meaning and possible utility for stakeholders in lower-resources settings remains abstract. This study drew together policymakers, public health practitioners, academics, health informaticians, health professionals, and people living with multimorbidity (PLWMM) in Zimbabwe to understand: What is the transformative potential and possible limitations of elevating multimorbidity as a priority in this setting? To bring these different perspectives into conversation, we used a participatory ethnographic design that involved a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. Multimorbidity, we found, was new to many respondents but generally viewed as a meaningful and useful concept. It foregrounded a range of challenges related to the ‘vertical’ organisation and uneven funding of different diseases, while revealing promising opportunities for integration across entrenched silos of knowledge and practice. However, with capacity and momentum to address multimorbidity currently concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming to restore the comprehensive primary care that undergirded Zimbabwe’s once-renowned health system. It also means building a policy-enabling environment that values generalist (as well as specialist) knowledge, ground-level experience, and inclusive stakeholder engagement. The ‘learning’ health system, we conclude, represents a promising conceptual lens for unifying these imperatives, providing a tangible framework for how knowledge, policy, and practice synergise within more self-reliant, person-centred health systems able to respond to ever-evolving complex health challenges like multimorbidity.
{"title":"Assembling the Challenge of Multimorbidity in Zimbabwe: A Participatory Ethnographic Study","authors":"Justin Dixon, Efison Dhodho, Fionah Mundoga, Karen Webb, Pugie Chimberengwa, Trudy Mhlanga, Tatenda Nhapi, Theonevus Tinashe Chinyanga, Justice Mudavanhu, Lee Nkala, Ronald Nyabereka, Gwati Gwati, Gerald Shambira, Trust Zaranyika, Clare I.R. Chandler, Rashida A. Ferrand, Chiratidzo Ndhlovu","doi":"10.1101/2024.08.06.24311557","DOIUrl":"https://doi.org/10.1101/2024.08.06.24311557","url":null,"abstract":"Multimorbidity, increasingly recognised as a global health challenge, has recently emerged on the health agendas of many lower-income countries, including in Africa. Yet with its conceptual origins in the global North, its meaning and possible utility for stakeholders in lower-resources settings remains abstract. This study drew together policymakers, public health practitioners, academics, health informaticians, health professionals, and people living with multimorbidity (PLWMM) in Zimbabwe to understand: What is the transformative potential and possible limitations of elevating multimorbidity as a priority in this setting? To bring these different perspectives into conversation, we used a participatory ethnographic design that involved a health facility survey, participant-observation, in-depth interviews, audio-visual diaries, and participatory workshops. Multimorbidity, we found, was new to many respondents but generally viewed as a meaningful and useful concept. It foregrounded a range of challenges related to the ‘vertical’ organisation and uneven funding of different diseases, while revealing promising opportunities for integration across entrenched silos of knowledge and practice. However, with capacity and momentum to address multimorbidity currently concentrated within the HIV programme, there was concern that multimorbidity could itself become verticalized, undercutting its transformative potential. Participants agreed that responding to multimorbidity requires a decisive shift from vertical, disease-centred programming to restore the comprehensive primary care that undergirded Zimbabwe’s once-renowned health system. It also means building a policy-enabling environment that values generalist (as well as specialist) knowledge, ground-level experience, and inclusive stakeholder engagement. The ‘learning’ health system, we conclude, represents a promising conceptual lens for unifying these imperatives, providing a tangible framework for how knowledge, policy, and practice synergise within more self-reliant, person-centred health systems able to respond to ever-evolving complex health challenges like multimorbidity.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"59 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-07DOI: 10.1101/2024.08.06.24311583
Song Xue, Guoqing Wu
Background: Stroke is the second leading cause of death and the primary cause of disability worldwide. Metabolic risks are major contributors to stroke. The global trends in metabolic risk-related stroke from 1990 to 2019, and the differences in mortality and DALYs across various demographic factors, remain unclear. Methods: All analyses were based on rates derived from the GBD2021 results (https://vizhub.healthdata.org/gbd-results/). Data were stratified by gender, region, and age. Joinpoint software was used to perform regression analysis of the average annual percent change (AAPC) and its 95% confidence interval to analyze trends from 1990 to 2019. Excel, PowerPoint, and R software were used for plotting and analysis, with p<0.05 considered statistically significant. Results: From 1990 to 2019, the average annual percent change (AAPC) for age-standardized rates (ASR) of DALYs was -1.70% (-1.81%, -1.58%), and for mortality, the AAPC was -1.57% (-1.68%, -1.46%). As the SDI increased, both the ASR of DALYs and mortality in 2019 showed a significant decline. The AAPC from 1990 to 2019 also exhibited a downward trend with increasing SDI levels. The DALYs and mortality rates of metabolic risk-related stroke predominantly affected individuals aged 75 and above, with a lesser impact on those under 55. For both genders, the 10-55 and 50-74 age groups had the highest DALYs and mortality rates due to metabolic-related intracerebral hemorrhage. For those aged 75-84 and over 85, ischemic stroke was the leading subtype of metabolic-related stroke contributing to DALYs and mortality rates. Conclusion: This is the first retrospective study on metabolic risk-related stroke on a global scale, summarizing its temporal trends and demographic distribution characteristics. Effective public health strategies are needed to address these disparities and continue reducing the global burden of metabolic risk-related strokes.
{"title":"Global Stroke Burden from Metabolic Risks Across Demographics: Findings from the 2021 Global Burden of Disease Study","authors":"Song Xue, Guoqing Wu","doi":"10.1101/2024.08.06.24311583","DOIUrl":"https://doi.org/10.1101/2024.08.06.24311583","url":null,"abstract":"Background: Stroke is the second leading cause of death and the primary cause of disability worldwide. Metabolic risks are major contributors to stroke. The global trends in metabolic risk-related stroke from 1990 to 2019, and the differences in mortality and DALYs across various demographic factors, remain unclear.\u0000Methods: All analyses were based on rates derived from the GBD2021 results (https://vizhub.healthdata.org/gbd-results/). Data were stratified by gender, region, and age. Joinpoint software was used to perform regression analysis of the average annual percent change (AAPC) and its 95% confidence interval to analyze trends from 1990 to 2019. Excel, PowerPoint, and R software were used for plotting and analysis, with p<0.05 considered statistically significant.\u0000Results: From 1990 to 2019, the average annual percent change (AAPC) for age-standardized rates (ASR) of DALYs was -1.70% (-1.81%, -1.58%), and for mortality, the AAPC was -1.57% (-1.68%, -1.46%). As the SDI increased, both the ASR of DALYs and mortality in 2019 showed a significant decline. The AAPC from 1990 to 2019 also exhibited a downward trend with increasing SDI levels. The DALYs and mortality rates of metabolic risk-related stroke predominantly affected individuals aged 75 and above, with a lesser impact on those under 55. For both genders, the 10-55 and 50-74 age groups had the highest DALYs and mortality rates due to metabolic-related intracerebral hemorrhage. For those aged 75-84 and over 85, ischemic stroke was the leading subtype of metabolic-related stroke contributing to DALYs and mortality rates.\u0000Conclusion: This is the first retrospective study on metabolic risk-related stroke on a global scale, summarizing its temporal trends and demographic distribution characteristics. Effective public health strategies are needed to address these disparities and continue reducing the global burden of metabolic risk-related strokes.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"23 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941413","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-07DOI: 10.1101/2024.08.05.24311509
Daehyun D Kim, Jenna M Swarthout, Colin Worby, Benard Chieng, John Mboya, Ashlee M Earl, Sammy M Njenga, Amy Pickering
Identifying bacterial transmission pathways is crucial to inform strategies aimed at curbing the spread of pathogenic and antibiotic-resistant bacteria, especially in rapidly urbanizing low- and middle-income countries. In this study, we assessed bacterial strain-sharing and dissemination of antibiotic resistance across humans, domesticated poultry, canines, household soil, and drinking water in urban informal settlements in Nairobi, Kenya. We collected 321 samples from 50 households and performed Pooling Isolated Colonies-seq (PIC-seq) by sequencing pools of up to five Escherichia coli colonies per sample to capture strain diversity, strain-sharing patterns, and overlap of antibiotic-resistant genes (ARGs). Bacterial strains isolated from the household environment carried clinically relevant ARGs, reinforcing the role of the environment in antibiotic resistance dissemination. Strain-sharing rates and resistome similarities across sample types were strongly correlated within households, suggesting clonal spread of bacteria is a main driver of dissemination of ARGs in the domestic urban environment. Within households, E. coli strain-sharing was rare between humans and animals but more frequent between humans and drinking water. E. coli contamination in stored drinking water was also associated with higher strain-sharing between humans in the same household. Our study demonstrates that contaminated drinking water facilitates human to human strain sharing and water treatment can disrupt transmission.
{"title":"Bacterial strain sharing between humans, animals, and the environment among urban households","authors":"Daehyun D Kim, Jenna M Swarthout, Colin Worby, Benard Chieng, John Mboya, Ashlee M Earl, Sammy M Njenga, Amy Pickering","doi":"10.1101/2024.08.05.24311509","DOIUrl":"https://doi.org/10.1101/2024.08.05.24311509","url":null,"abstract":"Identifying bacterial transmission pathways is crucial to inform strategies aimed at curbing the spread of pathogenic and antibiotic-resistant bacteria, especially in rapidly urbanizing low- and middle-income countries. In this study, we assessed bacterial strain-sharing and dissemination of antibiotic resistance across humans, domesticated poultry, canines, household soil, and drinking water in urban informal settlements in Nairobi, Kenya. We collected 321 samples from 50 households and performed Pooling Isolated Colonies-seq (PIC-seq) by sequencing pools of up to five Escherichia coli colonies per sample to capture strain diversity, strain-sharing patterns, and overlap of antibiotic-resistant genes (ARGs). Bacterial strains isolated from the household environment carried clinically relevant ARGs, reinforcing the role of the environment in antibiotic resistance dissemination. Strain-sharing rates and resistome similarities across sample types were strongly correlated within households, suggesting clonal spread of bacteria is a main driver of dissemination of ARGs in the domestic urban environment. Within households, E. coli strain-sharing was rare between humans and animals but more frequent between humans and drinking water. E. coli contamination in stored drinking water was also associated with higher strain-sharing between humans in the same household. Our study demonstrates that contaminated drinking water facilitates human to human strain sharing and water treatment can disrupt transmission.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"23 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941516","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-07DOI: 10.1101/2024.08.06.24311571
Andre J. McDonald, Amanda Doggett, Kyla Belisario, Jessica Gillard, Jane De Jesus, Emily Vandehei, Laura Lee, Jillian Halladay, James MacKillop
Importance: A growing number of jurisdictions have legalized recreational cannabis for adults, but most evaluations have used repeated cross-sectional designs, preventing examination of within-person and subgroup trajectories across legalization. Objective: To examine changes in cannabis use and misuse in the five years following legalization in Canada - the first G7 country to legalize adult recreational cannabis use - both overall and by pre-legalization cannabis use frequency using a longitudinal design. Design: Prospective cohort study with 11 biannual assessments from September 2018 to October 2023. Mean retention was 90% across all waves. Setting: Ontario, Canada. Participants: Sample of 1,428 (60.2% female, Mage=34.5) community adults aged 18 to 65 years. Exposure: Five years of recreational cannabis legalization (the baseline wave was immediately prior to legalization). Main outcome and measures: Primary outcomes were cannabis use frequency and cannabis misuse (CUDIT-R score). Pre-legalization cannabis use frequency, age, and sex were examined as moderators. Secondary outcomes included changes in cannabis product preferences over time. Results: Linear mixed effects modelling found a significant increase in cannabis use frequency, such that the mean proportion of days using cannabis increased by 0.35% (p<.001) per year in the overall sample (1.75% over 5 years). In contrast, CUDIT-R scores (on scale of 0 to 32) decreased significantly overall (b=-0.08 [-0.4 over 5 years], p<.001), most notably following the onset of the COVID-19 pandemic. Interaction analyses indicated that pre-legalization cannabis use frequency significantly moderated changes for both outcomes (p<.001). Specifically, cannabis use and misuse decreased among pre-legalization frequent consumers and modestly increased among occasional/non-users. Cannabis product preferences shifted away from dried flower, hashish, concentrates, oil, tinctures, and topicals to edibles, liquids, and vape pens. Conclusions and Relevance: In the five years following legalization, cannabis use frequency increased modestly, while cannabis misuse decreased modestly in a longitudinal observational cohort of Canadian adults. These changes were substantially moderated by pre-legalization cannabis use, with more frequent consumers of cannabis pre-legalization exhibiting the largest decreases in both outcomes. Although longer-term surveillance is required, these results suggest Canadian recreational cannabis legalization was associated with modest negative consequences and some evidence of positive outcomes among nonclinical community adults.
{"title":"Longitudinal changes in cannabis use and misuse in the 5 years following recreational cannabis legalization in Canada: A prospective cohort study of community adults","authors":"Andre J. McDonald, Amanda Doggett, Kyla Belisario, Jessica Gillard, Jane De Jesus, Emily Vandehei, Laura Lee, Jillian Halladay, James MacKillop","doi":"10.1101/2024.08.06.24311571","DOIUrl":"https://doi.org/10.1101/2024.08.06.24311571","url":null,"abstract":"Importance: A growing number of jurisdictions have legalized recreational cannabis for adults, but most evaluations have used repeated cross-sectional designs, preventing examination of within-person and subgroup trajectories across legalization. Objective: To examine changes in cannabis use and misuse in the five years following legalization in Canada - the first G7 country to legalize adult recreational cannabis use - both overall and by pre-legalization cannabis use frequency using a longitudinal design. Design: Prospective cohort study with 11 biannual assessments from September 2018 to October 2023. Mean retention was 90% across all waves. Setting: Ontario, Canada. Participants: Sample of 1,428 (60.2% female, Mage=34.5) community adults aged 18 to 65 years. Exposure: Five years of recreational cannabis legalization (the baseline wave was immediately prior to legalization). Main outcome and measures: Primary outcomes were cannabis use frequency and cannabis misuse (CUDIT-R score). Pre-legalization cannabis use frequency, age, and sex were examined as moderators. Secondary outcomes included changes in cannabis product preferences over time. Results: Linear mixed effects modelling found a significant increase in cannabis use frequency, such that the mean proportion of days using cannabis increased by 0.35% (p<.001) per year in the overall sample (1.75% over 5 years). In contrast, CUDIT-R scores (on scale of 0 to 32) decreased significantly overall (b=-0.08 [-0.4 over 5 years], p<.001), most notably following the onset of the COVID-19 pandemic. Interaction analyses indicated that pre-legalization cannabis use frequency significantly moderated changes for both outcomes (p<.001). Specifically, cannabis use and misuse decreased among pre-legalization frequent consumers and modestly increased among occasional/non-users. Cannabis product preferences shifted away from dried flower, hashish, concentrates, oil, tinctures, and topicals to edibles, liquids, and vape pens. Conclusions and Relevance: In the five years following legalization, cannabis use frequency increased modestly, while cannabis misuse decreased modestly in a longitudinal observational cohort of Canadian adults. These changes were substantially moderated by pre-legalization cannabis use, with more frequent consumers of cannabis pre-legalization exhibiting the largest decreases in both outcomes. Although longer-term surveillance is required, these results suggest Canadian recreational cannabis legalization was associated with modest negative consequences and some evidence of positive outcomes among nonclinical community adults.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-06DOI: 10.1101/2024.08.05.24311494
Rosie Mansfield, Marcus Richards, George B Ploubidis, Morag Henderson, Praveetha Patalay
Background and Objectives: Social isolation can be quantified using indicators across a range of social contexts e.g., household composition, friends and family, employment and community. Little is known about the way in which different forms of isolation differentially impact health, whether they produce a dose-response effect, and whether different forms of isolation interact in an additive or multiplicative way to impact psychological distress, life satisfaction and general health. The current study focuses on social isolation in mid-life, a life stage often neglected by the field. Research Design and Method: Data (N=32,391) were analysed from two successive British birth cohort studies: 1970 British Cohort Study (BCS) N=16,585 and the 1958 National Child Development Study (NCDS) N=15,806 focusing on participants social isolation during mid-life (ages 42-46). Linear multivariable regression models were run to investigate the independent, dose-response and interactive associations of social isolation indicators with psychological distress, life satisfaction and self-rated general health. Subsequently, all models were stratified to examine sex differences, and a cohort interaction was tested to assess cohort effects. An additional latent class analysis investigated whether different forms of isolation cluster in mid-life. Results: Independent associations varied by form of isolation and specific health outcomes, for instance, being out of education and employment was associated with all outcomes, living alone was only associated with lower life satisfaction and a lack of frequent contact with friends and relatives, no labour market participation and limited community engagement were associated with lower life satisfaction and self-rated general health. There was a dose-response relationship with higher social isolation scores associated with greater psychological distress, lower life satisfaction, and poorer self-reported general health. The effects of different combinations of social isolation on health appears to be additive, with no consistent sex and cohort differences observed. Conclusions: Results support a multi-domain, multi-context approach to studying social isolation and provides justification for research that investigates the separate and combined effects of different forms of social isolation; and the relevance of investigating social isolation in relation to the complete state of physical, mental and social wellbeing. Overall, isolation in its various forms was found to be detrimental for health, in mid-life, and over time in Great Britain. In particular, social isolation was associated most consistently with lower levels of life satisfaction. Efforts to reduce social isolation and its negative health impacts must recognise the complexity of experience across contexts and for different populations.
{"title":"Social isolation in mid-life: associations with psychological distress, life satisfaction and self-rated health in two successive British birth cohorts","authors":"Rosie Mansfield, Marcus Richards, George B Ploubidis, Morag Henderson, Praveetha Patalay","doi":"10.1101/2024.08.05.24311494","DOIUrl":"https://doi.org/10.1101/2024.08.05.24311494","url":null,"abstract":"Background and Objectives: Social isolation can be quantified using indicators across a range of social contexts e.g., household composition, friends and family, employment and community. Little is known about the way in which different forms of isolation differentially impact health, whether they produce a dose-response effect, and whether different forms of isolation interact in an additive or multiplicative way to impact psychological distress, life satisfaction and general health. The current study focuses on social isolation in mid-life, a life stage often neglected by the field. Research Design and Method: Data (N=32,391) were analysed from two successive British birth cohort studies: 1970 British Cohort Study (BCS) N=16,585 and the 1958 National Child Development Study (NCDS) N=15,806 focusing on participants social isolation during mid-life (ages 42-46). Linear multivariable regression models were run to investigate the independent, dose-response and interactive associations of social isolation indicators with psychological distress, life satisfaction and self-rated general health. Subsequently, all models were stratified to examine sex differences, and a cohort interaction was tested to assess cohort effects. An additional latent class analysis investigated whether different forms of isolation cluster in mid-life. Results: Independent associations varied by form of isolation and specific health outcomes, for instance, being out of education and employment was associated with all outcomes, living alone was only associated with lower life satisfaction and a lack of frequent contact with friends and relatives, no labour market participation and limited community engagement were associated with lower life satisfaction and self-rated general health. There was a dose-response relationship with higher social isolation scores associated with greater psychological distress, lower life satisfaction, and poorer self-reported general health. The effects of different combinations of social isolation on health appears to be additive, with no consistent sex and cohort differences observed.\u0000Conclusions: Results support a multi-domain, multi-context approach to studying social isolation and provides justification for research that investigates the separate and combined effects of different forms of social isolation; and the relevance of investigating social isolation in relation to the complete state of physical, mental and social wellbeing. Overall, isolation in its various forms was found to be detrimental for health, in mid-life, and over time in Great Britain. In particular, social isolation was associated most consistently with lower levels of life satisfaction. Efforts to reduce social isolation and its negative health impacts must recognise the complexity of experience across contexts and for different populations.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"11 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-06DOI: 10.1101/2024.08.05.24311505
Mony Thomas, Johnson Kirk, Raul Patel, Mary Fred
Background: Falls among older adults are a major public health concern, leading to significant morbidity, mortality, and healthcare costs. This systematic review and meta-analysis aimed to evaluate the effectiveness of falls prevention interventions for community-dwelling older adults aged 65 and above. Methods: We searched PubMed, Cochrane Library, CINAHL, Embase, and Web of Science databases for randomized controlled trials published between January 1, 2000, and December 31, 2023. Studies evaluating interventions designed to reduce fall incidence or fall-related injuries in community-dwelling older adults were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the RoB 2 tool. Meta-analyses were conducted using random-effects models. Results: Forty-seven studies met the inclusion criteria, involving 23,584 participants across 15 countries. The mean age of participants was 76.3 years (SD 4.7), and 68% were female. Overall, interventions significantly reduced fall rates (Rate Ratio 0.80, 95% CI 0.75-0.86, I=67%). Multifaceted interventions showed the greatest reduction in fall rates (RR 0.75, 95% CI 0.68-0.82), followed by exercise interventions alone (RR 0.85, 95% CI 0.78-0.92). Interventions also reduced the risk of becoming a faller (Risk Ratio 0.85, 95% CI 0.80-0.90) and the risk of fall-related injuries (Risk Ratio 0.83, 95% CI 0.76-0.91). Subgroup analyses revealed greater effectiveness in high-risk populations (RR 0.72, 95% CI 0.65-0.80). Longer interventions (12 months or more) showed greater reductions in fall rates. The mean adherence rate was 76%, with no serious adverse events reported. Conclusions: This review provides strong evidence supporting the implementation of multifaceted falls prevention programs for community-dwelling older adults, with a particular emphasis on exercise interventions. Future research should focus on long-term adherence, cost-effectiveness, and innovative approaches to fall prevention in diverse populations and settings.
背景：老年人跌倒是一个重大的公共卫生问题，会导致严重的发病率、死亡率和医疗成本。本系统综述和荟萃分析旨在评估针对 65 岁及以上居住在社区的老年人的跌倒预防干预措施的有效性：我们在 PubMed、Cochrane Library、CINAHL、Embase 和 Web of Science 数据库中检索了 2000 年 1 月 1 日至 2023 年 12 月 31 日期间发表的随机对照试验。纳入的研究评估了旨在减少社区老年人跌倒发生率或跌倒相关伤害的干预措施。两名审稿人独立筛选研究、提取数据，并使用 RoB 2 工具评估偏倚风险。采用随机效应模型进行元分析：47项研究符合纳入标准，涉及15个国家的23584名参与者。参与者的平均年龄为 76.3 岁（SD 4.7），68% 为女性。总体而言，干预措施大大降低了跌倒率（比率比 0.80，95% CI 0.75-0.86，I=67%）。多方面干预对跌倒率的降低幅度最大（RR 0.75，95% CI 0.68-0.82），其次是单纯的运动干预（RR 0.85，95% CI 0.78-0.92）。干预措施还降低了跌倒风险（风险比 0.85，95% CI 0.80-0.90）和跌倒相关伤害风险（风险比 0.83，95% CI 0.76-0.91）。分组分析显示，在高风险人群中，干预效果更好（RR 0.72，95% CI 0.65-0.80）。干预时间越长（12 个月或以上），跌倒率的降低幅度越大。平均坚持率为 76%，无严重不良事件报告：本综述提供了有力的证据，支持针对社区居住的老年人实施多方面的跌倒预防计划，并特别强调了运动干预。未来的研究应重点关注长期坚持率、成本效益以及在不同人群和环境中预防跌倒的创新方法。
{"title":"Standing Strong: A Systematic Review of Multifaceted Fall Prevention in Older Adults","authors":"Mony Thomas, Johnson Kirk, Raul Patel, Mary Fred","doi":"10.1101/2024.08.05.24311505","DOIUrl":"https://doi.org/10.1101/2024.08.05.24311505","url":null,"abstract":"Background: Falls among older adults are a major public health concern, leading to significant morbidity, mortality, and healthcare costs. This systematic review and meta-analysis aimed to evaluate the effectiveness of falls prevention interventions for community-dwelling older adults aged 65 and above.\u0000Methods: We searched PubMed, Cochrane Library, CINAHL, Embase, and Web of Science databases for randomized controlled trials published between January 1, 2000, and December 31, 2023. Studies evaluating interventions designed to reduce fall incidence or fall-related injuries in community-dwelling older adults were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the RoB 2 tool. Meta-analyses were conducted using random-effects models.\u0000Results: Forty-seven studies met the inclusion criteria, involving 23,584 participants across 15 countries. The mean age of participants was 76.3 years (SD 4.7), and 68% were female. Overall, interventions significantly reduced fall rates (Rate Ratio 0.80, 95% CI 0.75-0.86, I=67%). Multifaceted interventions showed the greatest reduction in fall rates (RR 0.75, 95% CI 0.68-0.82), followed by exercise interventions alone (RR 0.85, 95% CI 0.78-0.92). Interventions also reduced the risk of becoming a faller (Risk Ratio 0.85, 95% CI 0.80-0.90) and the risk of fall-related injuries (Risk Ratio 0.83, 95% CI 0.76-0.91). Subgroup analyses revealed greater effectiveness in high-risk populations (RR 0.72, 95% CI 0.65-0.80). Longer interventions (12 months or more) showed greater reductions in fall rates. The mean adherence rate was 76%, with no serious adverse events reported.\u0000Conclusions: This review provides strong evidence supporting the implementation of multifaceted falls prevention programs for community-dwelling older adults, with a particular emphasis on exercise interventions. Future research should focus on long-term adherence, cost-effectiveness, and innovative approaches to fall prevention in diverse populations and settings.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"135 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-06DOI: 10.1101/2024.08.05.24311372
Devin Daeschel, Long Chen, Claire Zoellner, Abigail B Snyder
Outbreaks of Salmonella and other pathogens associated with low moisture foods have been caused by cross-contamination from the processing environment into product. We used Monte Carlo simulations to model the impact of hypothetical cross-contamination scenarios of Salmonella from production equipment into milk powder. Model outputs include the quantity and extent of contaminated product from a production line, which can be useful for comparing the efficacy of different cleaning interventions. We also modeled the cross-contamination of potential dry cleaning surrogates to see how they responded to cleaning interventions in comparison to Salmonella. Input parameters for the model included log reductions from wiping an inoculated surface with a dry towel and transfer coefficients from an inoculated surface into milk powder that were measured experimentally and fitted to probability distributions. After a 2 log CFU contamination breach, the number of consumer size milk powder units (300 g) contaminated with Salmonella was 72 [24, 96] (median [p5, p95] across 1000 simulation iterations). The average concentration of Salmonella within contaminated units was -2.33 log CFU/g [-2.46, -1.86]. Wiping with a dry towel reduced the number of contaminated units to 26 [12, 64]. After product flushing with 150 kg of milk powder, the number of contaminated units dropped to 0 [0, 41]. E. faecium was the most appropriate surrogate for Salmonella transfer from surface to milk powder, while L. innocua was a more appropriate surrogate for the dry towel wiping intervention. These results suggest that product flushing, and to a lesser degree dry wiping, may be effective interventions in reducing contaminated milk powder product after a contamination breach. Further, simulation modeling is a useful tool for evaluating Salmonella dry transfer surrogates for their use in dry cleaning validation and modeling applications.
{"title":"A SIMULATION MODEL TO QUANTIFY THE EFFICACY OF DRY CLEANING INTERVENTIONS ON A CONTAMINATED MILK POWDER LINE","authors":"Devin Daeschel, Long Chen, Claire Zoellner, Abigail B Snyder","doi":"10.1101/2024.08.05.24311372","DOIUrl":"https://doi.org/10.1101/2024.08.05.24311372","url":null,"abstract":"Outbreaks of Salmonella and other pathogens associated with low moisture foods have been caused by cross-contamination from the processing environment into product. We used Monte Carlo simulations to model the impact of hypothetical cross-contamination scenarios of Salmonella from production equipment into milk powder. Model outputs include the quantity and extent of contaminated product from a production line, which can be useful for comparing the efficacy of different cleaning interventions. We also modeled the cross-contamination of potential dry cleaning surrogates to see how they responded to cleaning interventions in comparison to Salmonella. Input parameters for the model included log reductions from wiping an inoculated surface with a dry towel and transfer coefficients from an inoculated surface into milk powder that were measured experimentally and fitted to probability distributions. After a 2 log CFU contamination breach, the number of consumer size milk powder units (300 g) contaminated with Salmonella was 72 [24, 96] (median [p5, p95] across 1000 simulation iterations). The average concentration of Salmonella within contaminated units was -2.33 log CFU/g [-2.46, -1.86]. Wiping with a dry towel reduced the number of contaminated units to 26 [12, 64]. After product flushing with 150 kg of milk powder, the number of contaminated units dropped to 0 [0, 41]. E. faecium was the most appropriate surrogate for Salmonella transfer from surface to milk powder, while L. innocua was a more appropriate surrogate for the dry towel wiping intervention. These results suggest that product flushing, and to a lesser degree dry wiping, may be effective interventions in reducing contaminated milk powder product after a contamination breach. Further, simulation modeling is a useful tool for evaluating Salmonella dry transfer surrogates for their use in dry cleaning validation and modeling applications.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"40 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941542","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-05DOI: 10.1101/2024.08.02.24311417
Benjamin Fox, Joy Jiang, Sajila Wickramaratne, Patricia Kovatch, Mayte Suarez-Farinas, Neomi A Shah, Ankit Parekh, Girish N Nadkarni
Study Objectives. To investigate whether a foundational transformer model using 8-hour, multichannel data from polysomnograms can outperform existing artificial intelligence (AI) methods for sleep stage classification. Methods. We utilized the Sleep Heart Health Study (SHHS) visits 1 and 2 for training and validation and the Multi-Ethnic Study of Atherosclerosis (MESA) for testing of our model. We trained a self-supervised foundational transformer (called PFTSleep) that encodes 8-hour long sleep studies at 125 Hz with 7 signals including brain, movement, cardiac, oxygen, and respiratory channels. These encodings are used as input for training of an additional model to classify sleep stages, without adjusting the weights of the foundational transformer. We compared our results to existing AI methods that did not utilize 8-hour data or the full set of signals but did report evaluation metrics for the SHHS dataset. Results. We trained and validated a model with 8,444 sleep studies with 7 signals including brain, movement, cardiac, oxygen, and respiratory channels and tested on an additional 2,055 studies. In total, we trained and tested 587,944 hours of sleep study signal data. Area under the precision recall curve (AUPRC) scores were 0.82, 0.40, 0.53, 0.75, and 0.82 and area under the receiving operating characteristics curve (AUROC) scores were 0.99, 0.95, 0.96, 0.98, and 0.99 for wake, N1, N2, N3, and REM, respectively, on the SHHS validation set. For MESA, the AUPRC scores were 0.56, 0.16, 0.40, 0.45, and 0.65 and AUROC scores were 0.94, 0.77, 0.87, 0.91, and 0.96, respectively. Our model was compared to the longest context window state-of-the-art model and showed increases in macro evaluation scores, notably sensitivity (3.65% increase) and multi-class REM (3.39% increase) and wake (0.97% increase) F1 scores. Conclusions. Utilizing full night, multi-channel PSG data encodings derived from a foundational transformer improve sleep stage classification over existing methods.
{"title":"A foundational transformer leveraging full night, multichannel sleep study data accurately classifies sleep stages","authors":"Benjamin Fox, Joy Jiang, Sajila Wickramaratne, Patricia Kovatch, Mayte Suarez-Farinas, Neomi A Shah, Ankit Parekh, Girish N Nadkarni","doi":"10.1101/2024.08.02.24311417","DOIUrl":"https://doi.org/10.1101/2024.08.02.24311417","url":null,"abstract":"Study Objectives. To investigate whether a foundational transformer model using 8-hour, multichannel data from polysomnograms can outperform existing artificial intelligence (AI) methods for sleep stage classification. Methods. We utilized the Sleep Heart Health Study (SHHS) visits 1 and 2 for training and validation and the Multi-Ethnic Study of Atherosclerosis (MESA) for testing of our model. We trained a self-supervised foundational transformer (called PFTSleep) that encodes 8-hour long sleep studies at 125 Hz with 7 signals including brain, movement, cardiac, oxygen, and respiratory channels. These encodings are used as input for training of an additional model to classify sleep stages, without adjusting the weights of the foundational transformer. We compared our results to existing AI methods that did not utilize 8-hour data or the full set of signals but did report evaluation metrics for the SHHS dataset. Results. We trained and validated a model with 8,444 sleep studies with 7 signals including brain, movement, cardiac, oxygen, and respiratory channels and tested on an additional 2,055 studies. In total, we trained and tested 587,944 hours of sleep study signal data. Area under the precision recall curve (AUPRC) scores were 0.82, 0.40, 0.53, 0.75, and 0.82 and area under the receiving operating characteristics curve (AUROC) scores were 0.99, 0.95, 0.96, 0.98, and 0.99 for wake, N1, N2, N3, and REM, respectively, on the SHHS validation set. For MESA, the AUPRC scores were 0.56, 0.16, 0.40, 0.45, and 0.65 and AUROC scores were 0.94, 0.77, 0.87, 0.91, and 0.96, respectively. Our model was compared to the longest context window state-of-the-art model and showed increases in macro evaluation scores, notably sensitivity (3.65% increase) and multi-class REM (3.39% increase) and wake (0.97% increase) F1 scores. Conclusions. Utilizing full night, multi-channel PSG data encodings derived from a foundational transformer improve sleep stage classification over existing methods.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"8 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941543","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-05DOI: 10.1101/2024.08.04.24311467
Kh. Shafiur Rahaman, Marvin Marquez, Sarah Bick, Bella Monse, Dexter Galban, Habib Benzian, Robert Dreibelbis
Improving school water, sanitation, and hygiene (WASH) services in low-resources setting is a challenge. The Department of Education (DepEd) of the Philippines, supported by GIZ and UNICEF, runs the national WASH in schools program which promotes a stepwise approach to reach national WinS Standards and foster the institutionalization of WASH in the education sector. This includes national-level annual monitoring on WASH service levels in schools, information which is used to set target and allocation resources. Since 2019, the programme has also included a Massive Open Online Course (MOOC) for school staff. This platform provides uniform implementation guidance of WinS in the schools across the country. In this analysis, we use annual WASH monitoring data from the 2017/2018 (baseline) and 2021/2022 (endline) and compare this against school-level information on MOOC enrolment and completion. For each school in our analysis, we calculated baseline and endline overall and domain specific star ranking, a standardized 3-point composite measure of school WASH services adopted by DepEd. Linear regression models assessed the relationship between school staff participation in the MOOC and average change in star ranking between baseline and endline and logistic regression models were used to calculate the odds of improvement in star ranking between baseline and endline. Baseline and endline data were available for 28,779 schools. Of those, 5,980 schools had at least 1 teacher enrolled in the MOOC. Overall, MOOC participation was associated with improvements in both overall and domain specific star ranking, with larger improvements seen for hygiene services. The MOOC is a promising key component of the national WASH stategy complementing the annual monitoring process and warrants further investigation in the school management sector.
{"title":"Assessing the effect of a massive open online course (MOOC) on school water, sanitation, and hygiene improvements in the Philippines","authors":"Kh. Shafiur Rahaman, Marvin Marquez, Sarah Bick, Bella Monse, Dexter Galban, Habib Benzian, Robert Dreibelbis","doi":"10.1101/2024.08.04.24311467","DOIUrl":"https://doi.org/10.1101/2024.08.04.24311467","url":null,"abstract":"Improving school water, sanitation, and hygiene (WASH) services in low-resources setting is a challenge. The Department of Education (DepEd) of the Philippines, supported by GIZ and UNICEF, runs the national WASH in schools program which promotes a stepwise approach to reach national WinS Standards and foster the institutionalization of WASH in the education sector. This includes national-level annual monitoring on WASH service levels in schools, information which is used to set target and allocation resources. Since 2019, the programme has also included a Massive Open Online Course (MOOC) for school staff. This platform provides uniform implementation guidance of WinS in the schools across the country. In this analysis, we use annual WASH monitoring data from the 2017/2018 (baseline) and 2021/2022 (endline) and compare this against school-level information on MOOC enrolment and completion. For each school in our analysis, we calculated baseline and endline overall and domain specific star ranking, a standardized 3-point composite measure of school WASH services adopted by DepEd. Linear regression models assessed the relationship between school staff participation in the MOOC and average change in star ranking between baseline and endline and logistic regression models were used to calculate the odds of improvement in star ranking between baseline and endline. Baseline and endline data were available for 28,779 schools. Of those, 5,980 schools had at least 1 teacher enrolled in the MOOC. Overall, MOOC participation was associated with improvements in both overall and domain specific star ranking, with larger improvements seen for hygiene services. The MOOC is a promising key component of the national WASH stategy complementing the annual monitoring process and warrants further investigation in the school management sector.","PeriodicalId":501276,"journal":{"name":"medRxiv - Public and Global Health","volume":"99 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141941520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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